Left Main Revascularization With PCI or CABG in Patients With Chronic Kidney Disease: EXCEL Trial

Gennaro Giustino, Roxana Mehran, Patrick W. Serruys, Joseph F. Sabik, Milan Milojevic, Charles A. Simonton, John D. Puskas, David E. Kandzari, Marie Claude Morice, David P. Taggart, Anthony H. Gershlick, Philippe Généreux, Zixuan Zhang, Thomas McAndrew, Björn Redfors, Michael Ragosta, Irving L. Kron, Ovidiu Dressler, Martin B. Leon, Stuart J. PocockOri Ben-Yehuda, Arie Pieter Kappetein, Gregg W. Stone

Research output: Contribution to journalArticle

9 Citations (Scopus)

Abstract

Background: The optimal revascularization strategy for patients with left main coronary artery disease (LMCAD) and chronic kidney disease (CKD) remains unclear. Objectives: This study investigated the comparative effectiveness of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery in patients with LMCAD and low or intermediate anatomical complexity according to baseline renal function from the multicenter randomized EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. Methods: CKD was defined as an estimated glomerular filtration rate <60 ml/min/1.73 m2 using the CKD Epidemiology Collaboration equation. Acute renal failure (ARF) was defined as a serum creatinine increase ≥5.0 mg/dl from baseline or a new requirement for dialysis. The primary composite endpoint was the composite of death, myocardial infarction (MI), or stroke at 3-year follow-up. Results: CKD was present in 361 of 1,869 randomized patients (19.3%) in whom baseline estimated glomerular filtration rate was available. Patients with CKD had higher 3-year rates of the primary endpoint compared with those without CKD (20.8% vs. 13.5%; hazard ratio [HR]: 1.60; 95% confidence interval [CI]: 1.22 to 2.09; p = 0.0005). ARF within 30 days occurred more commonly in patients with compared with those without CKD (5.0% vs. 0.8%; p < 0.0001), and was strongly associated with the 3-year risk of death, stroke, or MI (50.7% vs. 14.4%; HR: 4.59; 95% CI: 2.73 to 7.73; p < 0.0001). ARF occurred less commonly after revascularization with PCI compared with CABG both in patients with CKD (2.3% vs. 7.7%; HR: 0.28; 95% CI: 0.09 to 0.87) and in those without CKD (0.3% vs. 1.3%; HR: 0.20; 95% CI: 0.04 to 0.90; pinteraction = 0.71). There were no significant differences in the rates of the primary composite endpoint after PCI and CABG in patients with CKD (23.4% vs. 18.1%; HR: 1.25; 95% CI: 0.79 to 1.98) and without CKD (13.4% vs. 13.5%; HR: 0.97; 95% CI: 0.73 to 1.27; pinteraction = 0.38). Conclusions: Patients with CKD undergoing revascularization for LMCAD in the EXCEL trial had increased rates of ARF and reduced event-free survival. ARF occurred less frequently after PCI compared with CABG. There were no significant differences between PCI and CABG in terms of death, stroke, or MI at 3 years in patients with and without CKD. (EXCEL Clinical Trial [EXCEL]; NCT01205776)

Original languageEnglish (US)
Pages (from-to)754-765
Number of pages12
JournalJournal of the American College of Cardiology
Volume72
Issue number7
DOIs
StatePublished - Aug 14 2018
Externally publishedYes

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Percutaneous Coronary Intervention
Chronic Renal Insufficiency
Coronary Artery Bypass
Transplants
Acute Kidney Injury
Confidence Intervals
Coronary Artery Disease
Stroke
Myocardial Infarction
Glomerular Filtration Rate
Disease-Free Survival
Dialysis
Creatinine
Epidemiology
Clinical Trials

All Science Journal Classification (ASJC) codes

  • Cardiology and Cardiovascular Medicine

Cite this

Giustino, G., Mehran, R., Serruys, P. W., Sabik, J. F., Milojevic, M., Simonton, C. A., ... Stone, G. W. (2018). Left Main Revascularization With PCI or CABG in Patients With Chronic Kidney Disease: EXCEL Trial. Journal of the American College of Cardiology, 72(7), 754-765. https://doi.org/10.1016/j.jacc.2018.05.057
Giustino, Gennaro ; Mehran, Roxana ; Serruys, Patrick W. ; Sabik, Joseph F. ; Milojevic, Milan ; Simonton, Charles A. ; Puskas, John D. ; Kandzari, David E. ; Morice, Marie Claude ; Taggart, David P. ; Gershlick, Anthony H. ; Généreux, Philippe ; Zhang, Zixuan ; McAndrew, Thomas ; Redfors, Björn ; Ragosta, Michael ; Kron, Irving L. ; Dressler, Ovidiu ; Leon, Martin B. ; Pocock, Stuart J. ; Ben-Yehuda, Ori ; Kappetein, Arie Pieter ; Stone, Gregg W. / Left Main Revascularization With PCI or CABG in Patients With Chronic Kidney Disease : EXCEL Trial. In: Journal of the American College of Cardiology. 2018 ; Vol. 72, No. 7. pp. 754-765.
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title = "Left Main Revascularization With PCI or CABG in Patients With Chronic Kidney Disease: EXCEL Trial",
abstract = "Background: The optimal revascularization strategy for patients with left main coronary artery disease (LMCAD) and chronic kidney disease (CKD) remains unclear. Objectives: This study investigated the comparative effectiveness of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery in patients with LMCAD and low or intermediate anatomical complexity according to baseline renal function from the multicenter randomized EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. Methods: CKD was defined as an estimated glomerular filtration rate <60 ml/min/1.73 m2 using the CKD Epidemiology Collaboration equation. Acute renal failure (ARF) was defined as a serum creatinine increase ≥5.0 mg/dl from baseline or a new requirement for dialysis. The primary composite endpoint was the composite of death, myocardial infarction (MI), or stroke at 3-year follow-up. Results: CKD was present in 361 of 1,869 randomized patients (19.3{\%}) in whom baseline estimated glomerular filtration rate was available. Patients with CKD had higher 3-year rates of the primary endpoint compared with those without CKD (20.8{\%} vs. 13.5{\%}; hazard ratio [HR]: 1.60; 95{\%} confidence interval [CI]: 1.22 to 2.09; p = 0.0005). ARF within 30 days occurred more commonly in patients with compared with those without CKD (5.0{\%} vs. 0.8{\%}; p < 0.0001), and was strongly associated with the 3-year risk of death, stroke, or MI (50.7{\%} vs. 14.4{\%}; HR: 4.59; 95{\%} CI: 2.73 to 7.73; p < 0.0001). ARF occurred less commonly after revascularization with PCI compared with CABG both in patients with CKD (2.3{\%} vs. 7.7{\%}; HR: 0.28; 95{\%} CI: 0.09 to 0.87) and in those without CKD (0.3{\%} vs. 1.3{\%}; HR: 0.20; 95{\%} CI: 0.04 to 0.90; pinteraction = 0.71). There were no significant differences in the rates of the primary composite endpoint after PCI and CABG in patients with CKD (23.4{\%} vs. 18.1{\%}; HR: 1.25; 95{\%} CI: 0.79 to 1.98) and without CKD (13.4{\%} vs. 13.5{\%}; HR: 0.97; 95{\%} CI: 0.73 to 1.27; pinteraction = 0.38). Conclusions: Patients with CKD undergoing revascularization for LMCAD in the EXCEL trial had increased rates of ARF and reduced event-free survival. ARF occurred less frequently after PCI compared with CABG. There were no significant differences between PCI and CABG in terms of death, stroke, or MI at 3 years in patients with and without CKD. (EXCEL Clinical Trial [EXCEL]; NCT01205776)",
author = "Gennaro Giustino and Roxana Mehran and Serruys, {Patrick W.} and Sabik, {Joseph F.} and Milan Milojevic and Simonton, {Charles A.} and Puskas, {John D.} and Kandzari, {David E.} and Morice, {Marie Claude} and Taggart, {David P.} and Gershlick, {Anthony H.} and Philippe G{\'e}n{\'e}reux and Zixuan Zhang and Thomas McAndrew and Bj{\"o}rn Redfors and Michael Ragosta and Kron, {Irving L.} and Ovidiu Dressler and Leon, {Martin B.} and Pocock, {Stuart J.} and Ori Ben-Yehuda and Kappetein, {Arie Pieter} and Stone, {Gregg W.}",
year = "2018",
month = "8",
day = "14",
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language = "English (US)",
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journal = "Journal of the American College of Cardiology",
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Giustino, G, Mehran, R, Serruys, PW, Sabik, JF, Milojevic, M, Simonton, CA, Puskas, JD, Kandzari, DE, Morice, MC, Taggart, DP, Gershlick, AH, Généreux, P, Zhang, Z, McAndrew, T, Redfors, B, Ragosta, M, Kron, IL, Dressler, O, Leon, MB, Pocock, SJ, Ben-Yehuda, O, Kappetein, AP & Stone, GW 2018, 'Left Main Revascularization With PCI or CABG in Patients With Chronic Kidney Disease: EXCEL Trial', Journal of the American College of Cardiology, vol. 72, no. 7, pp. 754-765. https://doi.org/10.1016/j.jacc.2018.05.057

Left Main Revascularization With PCI or CABG in Patients With Chronic Kidney Disease : EXCEL Trial. / Giustino, Gennaro; Mehran, Roxana; Serruys, Patrick W.; Sabik, Joseph F.; Milojevic, Milan; Simonton, Charles A.; Puskas, John D.; Kandzari, David E.; Morice, Marie Claude; Taggart, David P.; Gershlick, Anthony H.; Généreux, Philippe; Zhang, Zixuan; McAndrew, Thomas; Redfors, Björn; Ragosta, Michael; Kron, Irving L.; Dressler, Ovidiu; Leon, Martin B.; Pocock, Stuart J.; Ben-Yehuda, Ori; Kappetein, Arie Pieter; Stone, Gregg W.

In: Journal of the American College of Cardiology, Vol. 72, No. 7, 14.08.2018, p. 754-765.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Left Main Revascularization With PCI or CABG in Patients With Chronic Kidney Disease

T2 - EXCEL Trial

AU - Giustino, Gennaro

AU - Mehran, Roxana

AU - Serruys, Patrick W.

AU - Sabik, Joseph F.

AU - Milojevic, Milan

AU - Simonton, Charles A.

AU - Puskas, John D.

AU - Kandzari, David E.

AU - Morice, Marie Claude

AU - Taggart, David P.

AU - Gershlick, Anthony H.

AU - Généreux, Philippe

AU - Zhang, Zixuan

AU - McAndrew, Thomas

AU - Redfors, Björn

AU - Ragosta, Michael

AU - Kron, Irving L.

AU - Dressler, Ovidiu

AU - Leon, Martin B.

AU - Pocock, Stuart J.

AU - Ben-Yehuda, Ori

AU - Kappetein, Arie Pieter

AU - Stone, Gregg W.

PY - 2018/8/14

Y1 - 2018/8/14

N2 - Background: The optimal revascularization strategy for patients with left main coronary artery disease (LMCAD) and chronic kidney disease (CKD) remains unclear. Objectives: This study investigated the comparative effectiveness of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery in patients with LMCAD and low or intermediate anatomical complexity according to baseline renal function from the multicenter randomized EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. Methods: CKD was defined as an estimated glomerular filtration rate <60 ml/min/1.73 m2 using the CKD Epidemiology Collaboration equation. Acute renal failure (ARF) was defined as a serum creatinine increase ≥5.0 mg/dl from baseline or a new requirement for dialysis. The primary composite endpoint was the composite of death, myocardial infarction (MI), or stroke at 3-year follow-up. Results: CKD was present in 361 of 1,869 randomized patients (19.3%) in whom baseline estimated glomerular filtration rate was available. Patients with CKD had higher 3-year rates of the primary endpoint compared with those without CKD (20.8% vs. 13.5%; hazard ratio [HR]: 1.60; 95% confidence interval [CI]: 1.22 to 2.09; p = 0.0005). ARF within 30 days occurred more commonly in patients with compared with those without CKD (5.0% vs. 0.8%; p < 0.0001), and was strongly associated with the 3-year risk of death, stroke, or MI (50.7% vs. 14.4%; HR: 4.59; 95% CI: 2.73 to 7.73; p < 0.0001). ARF occurred less commonly after revascularization with PCI compared with CABG both in patients with CKD (2.3% vs. 7.7%; HR: 0.28; 95% CI: 0.09 to 0.87) and in those without CKD (0.3% vs. 1.3%; HR: 0.20; 95% CI: 0.04 to 0.90; pinteraction = 0.71). There were no significant differences in the rates of the primary composite endpoint after PCI and CABG in patients with CKD (23.4% vs. 18.1%; HR: 1.25; 95% CI: 0.79 to 1.98) and without CKD (13.4% vs. 13.5%; HR: 0.97; 95% CI: 0.73 to 1.27; pinteraction = 0.38). Conclusions: Patients with CKD undergoing revascularization for LMCAD in the EXCEL trial had increased rates of ARF and reduced event-free survival. ARF occurred less frequently after PCI compared with CABG. There were no significant differences between PCI and CABG in terms of death, stroke, or MI at 3 years in patients with and without CKD. (EXCEL Clinical Trial [EXCEL]; NCT01205776)

AB - Background: The optimal revascularization strategy for patients with left main coronary artery disease (LMCAD) and chronic kidney disease (CKD) remains unclear. Objectives: This study investigated the comparative effectiveness of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery in patients with LMCAD and low or intermediate anatomical complexity according to baseline renal function from the multicenter randomized EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. Methods: CKD was defined as an estimated glomerular filtration rate <60 ml/min/1.73 m2 using the CKD Epidemiology Collaboration equation. Acute renal failure (ARF) was defined as a serum creatinine increase ≥5.0 mg/dl from baseline or a new requirement for dialysis. The primary composite endpoint was the composite of death, myocardial infarction (MI), or stroke at 3-year follow-up. Results: CKD was present in 361 of 1,869 randomized patients (19.3%) in whom baseline estimated glomerular filtration rate was available. Patients with CKD had higher 3-year rates of the primary endpoint compared with those without CKD (20.8% vs. 13.5%; hazard ratio [HR]: 1.60; 95% confidence interval [CI]: 1.22 to 2.09; p = 0.0005). ARF within 30 days occurred more commonly in patients with compared with those without CKD (5.0% vs. 0.8%; p < 0.0001), and was strongly associated with the 3-year risk of death, stroke, or MI (50.7% vs. 14.4%; HR: 4.59; 95% CI: 2.73 to 7.73; p < 0.0001). ARF occurred less commonly after revascularization with PCI compared with CABG both in patients with CKD (2.3% vs. 7.7%; HR: 0.28; 95% CI: 0.09 to 0.87) and in those without CKD (0.3% vs. 1.3%; HR: 0.20; 95% CI: 0.04 to 0.90; pinteraction = 0.71). There were no significant differences in the rates of the primary composite endpoint after PCI and CABG in patients with CKD (23.4% vs. 18.1%; HR: 1.25; 95% CI: 0.79 to 1.98) and without CKD (13.4% vs. 13.5%; HR: 0.97; 95% CI: 0.73 to 1.27; pinteraction = 0.38). Conclusions: Patients with CKD undergoing revascularization for LMCAD in the EXCEL trial had increased rates of ARF and reduced event-free survival. ARF occurred less frequently after PCI compared with CABG. There were no significant differences between PCI and CABG in terms of death, stroke, or MI at 3 years in patients with and without CKD. (EXCEL Clinical Trial [EXCEL]; NCT01205776)

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U2 - 10.1016/j.jacc.2018.05.057

DO - 10.1016/j.jacc.2018.05.057

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JO - Journal of the American College of Cardiology

JF - Journal of the American College of Cardiology

SN - 0735-1097

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